Same but Different: How Autistic Adults Describe Depressive Symptoms and Their Alignment with <i>DSM-5-TR</i> Criteria

Background: Autistic adults experience disproportionately high rates of depression, yet Diagnostic and Statistical Manual of Mental Disorders , 5th ed., text rev. (DSM-5-TR ) diagnostic criterion descriptions may not fully reflect their lived experiences, impacting opportunities for identification and support. Autism-related differences, such as alexithymia, interoception, cognitive styles, and sensory processing, may influence how autistic adults perceive, experience, and describe depression. This study examines whether autistic adults’ descriptions of depressive symptoms align with, or diverge from, DSM-5-TR criteria descriptions, to inform more accurate diagnostic practices. Methods: We conducted an exploratory qualitative study with 109 autistic adults and 13 caregivers, who reported on the autistic adult they support. Participants described depressive symptoms relative to their typical autistic baseline via an online survey ( n = 112) or semi-structured interview ( n = 10). Using direct content analysis, we identified symptoms consistent with DSM-5-TR symptom descriptions, and through inductive analysis, we identified additional features outside DSM-5-TR criteria. Results: Participants described depressive symptoms that both aligned with and diverged from DSM-5-TR descriptors. Participants often expressed depressed mood as anger or irritability, or as emotional numbness. Anhedonia involved a loss of enjoyment in deep interests ( autistic anhedonia ), a source of emotional regulation. They described fatigue as a pervasive physical heaviness and reported depression attacks , characterized by sudden, overwhelming suicidal ideation. Participants described depression as influencing autistic characteristics, including variations in sensory sensitivities, stronger insistence on sameness and routine, changes in hyperfocus within deep interests, and self-injurious behavior. They also reported that emotional awareness and expression difficulties, alongside heightened sensitivity and dysregulation, intensify during depression. Conclusion: Autistic adults described depressive symptoms, which we coded against DSM-5-TR criteria, and while most symptom descriptions aligned with DSM-5-TR criteria, some differed in form or expression. For some, reports suggested a bidirectional relationship between autistic characteristics and depression. Further understanding of autistic adults’ depressive symptoms is critical to improving diagnostic accuracy and guiding the design of autism-informed assessment tools.